The Development and Testing of a Framework for Understanding Implementation of the Patient-Centered Medical Home in Primary Care Clinics Abstract Research Objective: The Patient-Centered Medical Home (PCMH) is widely accepted as a model of practice redesign in transforming the healthcare system in the US;however, the complexity of implementing PCMH models in clinical practice is quite challenging. Extant research on the implementation of new organizational practices focuses predominately on the factors and process of implementing a single intervention. The PCMH is a complex multi- faceted program comprised of multiple clinical and managerial components requiring simultaneous implementation and organizational transformation. The primary aim of this study is to understand why some organizations succeed, while others fail, to successfully implement the PCMH. Conceptual Framework: Organizational theorists contend that successful intra-organizational change is a result of leadership supporting a balance of a clearly defined structure with flexibility and information exchange. An organizational learning perspective will be used to guide the development of a framework for understanding the duality of a defined organizational structure and flexible organizational coherence that must exist to achieve PCMH implementation. Methods: The underlying logic of this research is based on action ethnography and a hypothesizing of domains. This method is appropriate for investigating phenomena for which extant theory does not provide adequate insight. Preliminary information on twenty-five clinics affiliated with a single, large academic health system will be used to identify a qualitative sample of six clinics that vary along key organizational factors. In-depth comparative case studies will be carried out to evaluate how differences among the clinics affect variation in PCMH implementation. Primary sources of data will be observations and semi-structured interviews with three to eight individuals working in each of the clinics and recruited from a variety of roles. Using organizational theory and implementation science to structure an iterative thematic analysis of the data, organizational learning processes associated with varying levels of PCMH implementation success will be revealed. Mixed methods will be used to compare levels of PCMH implementation success with patient and organizational outcomes. Conclusion: The findings of this proposed research should reveal important considerations in the development of recommendations for PCMH implementation strategy, standardized PCMH guidelines for evaluating physician organizations, and the theoretical association between organizational learning and implementation. PUBLIC HEALTH RELEVANCE: The patient-centered medical home (PCMH) has recently been receiving considerable attention;however empirical research exploring how successful PCMH implementation occurs in healthcare organizations is needed to provide guidance to practitioners in adapting elements of the PCMH model within organizational work processes. The proposed research will develop and test a framework for understanding PCMH implementation in primary care clinics.